Anesthesia

The anesthetist reanimator in France

The anesthetist reanimator is a specialist physician. After the 6 years of university training and after nomination with the contest of the boarding school, an anesthetist-réanimateur currently obtains his qualification after ten six-month periods of training courses in an University hospital CHU (including two obligatory six-month periods in anesthesia, two obligatory six-month periods in reanimation and an obligatory six-month period in one of the two specialities to the choice).
Throughout its career, it can as well work with the operating room suite, in the intensive care units, with the urgencies, or the SAMU. Because of their control of technical epic private individuals (infiltrations, poses catheters…) certain anesthetists réanimateurs choose to make an additional training to work in the centers anti-pain.
The anesthetists are assisted by male nurses anesthetists (IADE) which carry out the anesthesias in collaboration with him or alone but always under its responsibility. The IADE are Infirmier S which, at the end of the initial training of male nurse (3 years and half) follow on contest 2 years of specialization in anesthesia and reanimation.

General anesthesia

The general anesthesia is a medical act whose main aim is the temporary suspension and reversible of the conscience and of the painful sensitivity, obtained using drugs managed by intravenous way and/or inhalatoire.

This key objective, allowing the realization without memorizing and Pain of the surgical interventions and some invasive examinations, joins the need for a continuous monitoring and often for an artificial control (mechanical and/or pharmacological) of the vital functions: Breathing (respiratory frequency, volume running, oxymetry), Hémodynamique (cardiac rhythm, blood pressure), Muscular tone. Because of specificities of the technical approach, physiopathological and pharmacological of the anaesthetized patient and safety requirement which surrounds this act, the practice of the general anesthesia is possible in France only under the control of the Médecin anesthetist-réanimateur.

Loco-regional anesthesia

The loco-regional anesthesia with the advantage of not involving a loss of conscience. The breathing and the reflexes of protection of the air routes are maintained. When the surgery allows it, the anesthesias of a member decrease the complications connected to the anesthesia (the patient is more quickly on foot): it is thus a technique of choice for the ambulatory surgery. One generally accompanies it by one sedation using a Benzodiazépine or by a Hypnotique with low dose. Nevertheless the total vital risk is not different between a general anesthesia and a rachidian anesthesia (epidural or Rachianesthésie) except for the Cesareans where the advantage goes to the rachidian anesthesia (from where are use in more than 95% of the cases).

Local anesthesia

This anesthesia is limited to the area concerned and is generally carried out by injection of Anesthésique S buildings in fabrics to anaesthetize or sometimes by the application of a frost or cream containing those. It is in general this technique which the dentists practice. The local anesthesia can be applied by the surgeon him even. The security standards must be respected because the allergic complications and the shock vagal can occur.

Regional anesthesia

It is about the anesthesia of the territory served by a nerve or a group of nerves. One obtains it by injecting a Local anesthetic near the nerve. The axial regional anesthesias are distinguished (rachianesthésies and anesthesias péridurales), which allow an anesthesia of the bottom of the body and the peripheral regional anesthesias which make it possible to act on a member or a segment of member.

Axial anesthesias: the anesthetic product is deposited either near marrow, in the liquid céphalorachidien (rachianesthesy), or near the nervous roots, on the level of the meninges (péridurale and caudal anesthesia). When a catheter (small pipe being used to inject drugs) is left in place, one can prolong the effect of the anesthesia, and modulate his power (in order to make analgesia, for example for the childbirth). These techniques thus require the realization of a puncture on the level of the back. The péridurale can be realized on all the floors of the spinal column. Realized on the level of the dorsal vertêbres, it is particularly useful to relieve the pains after thoracic surgery or high abdominal surgery.

The anesthesias tronculaires: one can anaesthetize only one arm, or a leg for example. The precise localization of the place where the anesthetic product must be deposited, is carried out thanks to a stimulative highly-strung person. That Ci makes it possible to locate the various nerves exactly to be blocked. One can also slip a catheter which will make it possible to inject anesthetic buildings to maintain the effect, and avoid the pains after the operation (operational analgesia post).

The regional anesthesias loco must always be realized by specialist physicians, trained with techic and knowing to manage the possible complications.

Anesthesia péridurale

History of the anesthesia

See also: History of the anesthesia

Juice of poppy, Indien hemp, Mandrake, sponges sleeping pills or opiated potion: these various soporific elixirs, more or less effective, were used to alleviate the pain until 1842. They were absorbed by ingestion of a decoction or inhalation of the smoke which they release while burning.

Indeed, since thousands of years, pullers of teeth, barbers and surgeons look after with great grip and wave actions the human body. With sharp! To attenuate the torment, only one solution: to work at any speed, some succeeding even of the amputations in a few tens of seconds! In XVIe century, the large surgeon Ambroise Paré recommends a cocktail of opium and alcohol with high amount and recoud the wounds instead of cauterizing them by an atrocious burn with red iron. During the retirement of Russia, Dominique Larrey, the surgeon of Napoleon notes that the great cold attenuates the pain of operated and one will keep a long time the process to cut down by the gangrenés members.

The true evolution proceeds the March 31st 1842 when the American doctor Crawford Length must practice a surface intervention on one of his patients; it has then the idea to deaden it while making him breathe ether. Unfortunately, it does not inform its fellow-members of its innovation, who fall into the lapse of memory.

Then, in December 1844, the dentist Horace Wells attends an entertaining scientific meeting where one observes the laughing effects of the nitrogen protoxide; he notes that a subject meurtrit without feeling any pain. The following day, it decides to be made tear off a tooth, anaesthetized by nitrogen protoxide. Persuaded of the success of the method, it leaves to the hospital Boston to make the demonstration of it: consequently technical, it carries out the extraction of a tooth which shows… a failure, and it undergoes the gibes of the students, who believe in a trickery.

The silence Length and the failure of Wells will make it possible two other doctors to share, or rather to dispute the discovery of the anesthesia by ether. The chemist Charles Thomas Jackson provides to the surgeon of the hospital of Boston William Morton the indications essential to his preparation and his administration. September 30th, 1846, Morton removes a tooth with a patient anaesthetized with ether poured on a handkerchief.

The ether is used for the first time in France, in 1847, whereas one of the most considered French surgeons, Velpeau, had declared, eight years earlier, that the surgery without pain was inconceivable.

After ether chloroform comes: The physiologist Pierre Flourens anesthesia of the animals to chloroform but it is James Young Simpson, gynecologist in Edinburgh, which, after having carried out a test on him and its assistants, regularly uses it as from 1847.

However, the anesthesia is not only the elimination of the pain, it is also a means Inhiber the muscular contraction. In 1844, Claude Bernard discovers that the Curare acts on the junction neuromusculaire involving a paralysis and a fall of the muscular tone; under the effect of curare, the muscles do not function any more, become soft, the lungs are immobilized. Because of the respiratory paralysis, the brain and the fabrics are not fed any more out of oxygen. Time passes and the doctors benefit from this observation only in 1942: on this date, a purified derivative, the intocotrine, extracted the reported plants with curare of Amazonia in 1938 is introduced in anesthésie.
If the first attempts at intravenous anesthesia seem to go back to 1872, it is the use of the hexobarbital which gives a kickoff to the method in 1932. Another barbiturate with fast action, the thiopental, is used for the first time in 1934; today, it is still used for the intravenous anesthesia. One will test then various Barbiturique S with fast action, but none will détrônera the famous thiopental. The new intravenous anesthetic agents multiply as from the years 1950.

The anesthesia by inhalation is the other way of deadening the patients: during nearly 100 years, chloroform and the ether are the anesthetic ones by inhalation. However, the risk of syncope mortal with chloroform is confirmed since 1848, and one gives up it with the profit of the ether, which yields the place to the nitrogen protoxide, still used as auxiliary analgesic. Then a fluorinated compound, the halothane, is synthesized: it was going to become the anesthetic by inhalation more used in the world in the years 1980. Let us return to Claude Bernard who, in 1860, proposes the combined anesthesia associating morphine and chloroform. This association became that of the anesthesia " today; balancée" where one associates various anesthetic, morphine analgesic and Myorelaxant managed by intravenous way or inhalation.

The combination of these various molecules minimizes the side effects of an anesthesia, thanks to a reduction in the amounts necessary. The first local anesthetic available was cocaine. It was used in ocular surgery by instillation of the 1884. The other anesthetic ones make their appearance; at the end of the century, cocaine is the first substance used in local anesthesia.

However its toxicity stimulated the search for new anesthetic buildings; the Lidocaïne, introduced in 1943 is the local anesthetic of reference, but it is supplanted more and more by more active molecules and less and less poisons.

At the beginning of the XXe century, the techniques and the equipment improve. The anesthesias, less toxic, can be now prolonged, which opens the field with operational acts hitherto impossible. After the Second world war, the anesthesia becomes an autonomous medical discipline, to which the reanimation is assistant.

In France, the representative learned society is since 1982 the French company of Anesthesia Reanimation (SFAR)

See too

Law of Meyer-Overton
Protoxide of nitrogen (NR ₂ O)

Mixture équimolaire oxygen-protoxide of nitrogen (MEOPA)

External bonds

French company of Anesthesia and Reanimation

Simple: Anesthetic

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